At this juncture once again, let me
layout the plan for meningitis for you.
Overall, the topic in neuropathology that
we are dealing with here is CNS infections
and up until this point, really, all of
everything we’ve done has been infections.
Now, this is a small topic but
just to make sure we’re clear.
Chemical meningitis, obviously,
this is not infectious,
but it behaves like your traditional
meningitis caused by infections.
Are we clear?
So maybe iatrogenic,
therefore, maybe myelography was being
done resulting in a chemical meningitis.
Drug related, NSAIDS,
penicillin, INH, and IVIG is
an important one, isn’t it?
There are a couple indications in
which IVIG would be recommended.
What if you had a child that had--
Take a look at the mucus of your child
and on the tongue specifically,
you find it to be strawberry covered or
looks like a skin of a strawberry.
You take a look at the sclera and the
conjunctiva, they are bilaterally injected.
You take a look at the skin itself
and it’s a desquamating rash
There’s a fever. No doubt, there’s a fever.
And there is cervical lymphadenopathy.
You put all these together and
I’m referring to Kawasaki.
In Kawasaki, your treatment of
choice would be what management?
Could also result in possibly
Just to make sure
that you're clear.
Say that your patient had an
intracranial dermoid tumor.
What does the dermoid tumor mean to you?
It’s one of those tumors that
you’ve heard about before,
in which instead of it being a
deep type of fibromatosis,
maybe perhaps missed tumor
and there is rupture resulting
in meningitis-type of symptoms.
You’ve heard of
something that you could find in a child
and usually what you thinking
about in this child?
Complication you’re looking for
is bitemporal hemianopsia.
Where are you?
In the sella turcica, right?
What does the sella mean to you?
It’s the home of your pituitary.
So when you say
your most common location and
age, a child, in the sella
in which it’s filled with --
We call it “crank oil"
and therefore causing severe
compression of the optic chiasm.
There is every possibility that there
might be a craniopharyngioma cyst
that will then rupture and when it does,
it may result in meningitis-type symptoms.
Let’s move on.
Here, we have leptomeningeal
Once again, not infections.
Diffuse seeding of leptomeninges
with metastatic tumor cells.
So say that your patient has
a severe type of astrocytoma,
grade 4 and what may then happen?
They might seed into the leptomeninges
resulting in meningitis type of symptoms.
Symptoms include your headache,
altered mental status,
which you can expect with a meningitis type
and you can also have cranial neuropathies.
So what kind of cancers you
might you be thinking about?
Now apart from glioblastoma
multiforme and seeding,
what if there is metastasis from
some of those other cancers
that you are very comfortable with
that might metastasize?
And these include breast
cancer, lung cancer,
more so small cell lung cancer,
your melanoma, medulloblastoma,
think about the most common brain tumor in
a child and your neuroendocrine tumors.
These may result in as soon as
Allow the name to speak to you,
it gives you meningitis type of
symptoms, but these are not infections.
These are metastatic
coming from other cancers.
Diagnosis: Imaging with MRI will then
show you leptomeningeal enhancement
and then obviously, you need
to do cytopathology analysis
of the cerebrospinal fluid.
in terms to diagnosis,
but you must make sure
that you keep in mind,
if your patient has cancer and
has meningitis type of issues,
your answer choice would be
We’ll come back to our
So with our infections, we’ll
continue our discussion,
but this time we'll
So here once again, what
I need you to do for me
is keep your spirochete separate from
mycobacteria, separate from bacterial.
Granted, spirochetes and mycobacterial
are bacterial, correct?
However, to make sense of
what’s going on clinically,
Keep the bacterial causes that
we’ve talked about in great detail
with age groups
separate from tuberculous meningitis
that we talked about in great detail
and then quickly here, some of the spirochetal
infections such as neurosyphilis.
We have borreliosis
Let’s talk about neurosyphilis.
So what happens here?
Use your tertiary.
Neurosyphilis, what may happen?
I close my eyes and I have lost my sense
of proprioception, positive Romberg.
What else may happen?
Lose your touch and vibration.
You’re referring to
your tabes dorsalis.
So 15-40% of primary and
patients have CSF abnormalities.
Very much could result
in CNS infections.
Can present with dementia only.
Can also present with meningitis
symptoms with variable focal findings
based on what part of the
brain has been affected.
Something that you’ve talked about
earlier is Argyle-Robertson Pupil.
What happens here?
So here, my topic is neurosyphilis.
Apart from tabes dorsalis which is
of the spinal cord, dorsal column.
Where are you now?
Unfortunately, the neurosyphilis has
migrated up into the cranial cavity
and therefore resulting in a
whole host of other issues.
So what’s Argyle-Robertson Pupil?
There is no direct or
consensual light response,
but pupils will constrict
Make sure you know the full definition
of Argyle-Robertson Pupil, please,
Or you could have a facial
nerve or the vestibulocochlear
or the most frequent
affected cranial nerves.
What does that mean to you?
Well, you might have difficulty with hearing
or balance, vestibulocochlear or facial.
So maybe you’re looking
at levator palpebrae.
Maybe issues with the
mouth and such, right?
you already know what happens in great
detail with microbiology and tabes dorsalis.
Here, I’m walking you through more
details that you need to make sure
that you’re familiar with
in terms of complications.
Diagnosis: CSF, but this time
what you are going to find?
Elevated protein with evidence of your?
What is the name of the
organism that causes syphilis?
So what does this mean to you?
Non-treponemal antigen test,
RPR or VDRL and
treponemal antigen test
and this refers to FTA-ABS, fluorescent
treponemal antibody absorption test.
Things that you’ve already talked
about in micro, all I’m doing here
is making sure that
I reinforce it.
Treatment: Penicillin G
for about 2 weeks or so.
Only of the few indications for
desensitization if penicillin allergy exists,
one of the few indications
Coexisting HIV infection can change
recommendation of your management altogether.
So when we start getting into our
HIV associated CNS infections,
HIV changes the ball
Continue our discussion with
spirochetal type of meningitis.
Here, we have Lyme disease.
So what does Lyme
disease mean to you?
You begin with your patient
up in New England.
So here we are in Northeast
part of the U.S.
And what do you with your friends?
So maybe you’re going out
and you’re hunting.
You’re hunting for what?
Well, maybe a deer.
You've heard of the deer tick and of
course, this brings us to our Ixodes.
And the organism, the spirochetes
specifically is the Borrelia burgdorferi
and you’ve heard of your target lesion.
What is this called?
Erythema chronicum migrans.
Are we clear about
all that from micro?
What may happen as complications
years down the road?
You could have arthritis, right?
Arthritis, don’t forget
that in rheumatology.
And the Lyme disease eventually could
also cause issues in the brain.
We know about our Ixodes,
What does that mean to you?
You know what a target looks like.
A central area of erythema surrounded by
pallor with a peripheral ring of erythema.
Now, our focus will be
on neurologic symptoms.
Granted it’s bacterial but unfortunately
we have to call this aseptic.
"But, Dr. Raj, it’s a bacteria."
It’s an infection.
Tell me that it’s an infection,
but you’re calling aseptic.
How many times have you
heard of aseptic already?
We know for a fact that it’s an infection.
For example, earlier, we talked
about some of your aseptic,
the type of valvular heart diseases
or vegetations or in other words,
I’m referring to what as
known as valvulopathies.
Sometimes it is called aseptic,
but you know for a fact that
there is organism such as HACEK.
Or what about prostatitis.
There is every possibility
that could be aseptic
but it is still could
be caused by infection.
So keep that in mind.
Facial nerve palsies is a
huge one from neuroanatomy.
Remember, any part of the brain could
be affected, both the parenchyma.
And polyneuropathies, number of
cranial nerves could be affected.
Keep these in mind.
Our topic is Lyme disease, but specifically
causing infection in the brain.
Treatment here, amoxicillin
or IV ceftriaxone can be used
if symptoms are quite severe.